Archive for category Rural Emergency Medicine

I was sitting in the atrium at the Chihuly Garden and Glass Museum in Seattle during the ACEP Scientific Assembly a couple of weeks ago enjoying a glass of wine and some fine appetizers, so it took me a moment to think about what my colleague was asking me. And, to be honest, I wasn’t sure if I could answer her question.

I joked back, “Love is such a strong word…” But, her question really put me in a pensive mood. Did I still love it? At a time when more patients are going to the emergency department because they can’t find a primary doctor, or don’t have insurance or have just gotten insurance and have put off having any routine medical care until today, and at a time when government fund cutbacks mean stricter measures for payment of fees (i.e., if you don’t get good patient satisfaction scores, we’re not going to pay you) it’s hard to be an ED doc and not develop a certain level of cynicism.

I’ve already written about my decision to return to Emergency Medicine after having trained in Surgery in prior posts. I wanted variety, continued challenges, the ability to go home at the end of my shift knowing I wouldn’t get called back into the hospital just as I was getting settled in for the night. And, for the most part, I do enjoy my job. But there are those days when I wonder if I wouldn’t be happier as a cashier… or a waitress… or….? I think about what my application would look like… Prior Work Experience: dealing daily with irrational people having unrealistic expectations and demanding all their problems get solved promptly. I guess maybe they’d tell me I was over qualified.

Then I think about those moments of pure chaos, when you weren’t sure if you were making the right decision at the time, and you relied solely on pure guts and instinct with whisperings of medical knowledge; when both you and the patient came out slightly bruised and beaten on the other side but alive to fight another day. Those are the moments when you truly feel you have made a difference; that those 10 years of post-graduate education weren’t a waste of time.

Those are the days when I do love my job. And, they’re the ones that keep me going…

Find a job you enjoy, and you will never have to work a day in your life.

She was young, pretty, and dead. Another victim of a head-on collision on a stretch of winding road outside of town where we get the great majority of MVC’s in the rural hospital in which I work. We knew it was going to be bad when we heard the ambulance traffic call out the “Code Three with one” as it was en route from the accident site.

She was resuscitated, but after an hour we knew that nothing more could be done for her. After calling the code, my attention turned to the sometimes worst part of our job, notifying the next of kin. She had a cell phone in her bag, and on it “Mommy.”

I can still hear her voice as she cheerily answered “Hi! Good morning!” Had I been in a different frame of mind, I would have taken the time to try to figure out how to find the actual number in her contact list. But, Monday morning quarterbacking aside, I did what my instincts told me to do at that moment.

Once I said that her daughter had been in a serious accident, she immediately passed me off to the girl’s father “who was a doctor and would understand better.” I steadied my voice as I informed him that his daughter had died. I held the phone near my ear but somewhat away as the wails and cries filled the small space I was in. Their grief carrying across the hundreds of miles that separated us.

They would come right away, he reassured me. I told him to take his time and await our phone call. There were other calls that had to be made. To CHP. To the donor network. To the coroner. After about an hour, my nursing supervisor told me the family was coming and would like to stop by the hospital to talk to me.

Several hours and a multitude of patients later, they arrived. I spent some time with them explaining what I knew of the accident and about the resuscitation effort. As a doctor, he had a lot of questions and wanted to know everything in detail. Toward the end of the visit, I found out she had only recently moved and was actually working at one of our local shops.

Then I remembered her. A bright, smiling girl who helped me with a purchase not even a week ago. I tried to wrap my head around that image and not of the broken patient who had been brought to my ED just hours earlier. I’m still trying.

I think we’ve all experienced what I like to call “case envy.” Or even sometimes, “shift envy.” You come on and your colleague immediately starts telling you about the interesting case, or the polytrauma, or the fantastic save/diagnosis/procedure that they just completed.

“Hey, bud, I just performed an open thoracotomy, cross-clamped the aorta and threw in a central line just after performing a cric while I was watching this guy’s aorta rupture during my ultrasound of his belly during which we lost pulses. Sorry about the rest of the mess here in the ED, but those three pelvics and a disempaction might yield something interesting… Enjoy your shift!”

Yeah…

I sometimes hear the story and wonder what I might have done. Would I have handled things the same way? Is that the diagnostic approach I would have followed? Would I even have considered things the same way? Why don’t I ever get the cool cases…?

In residency, we had one colleague who was the perpetual “Black Cloud.” Now, they got to see a lot of cool stuff. However, you didn’t want to follow them because you knew it was going to be chaos in the ED when you arrived. And, if you came before them, you knew the last part of your shift was going to start going to pot about an hour before the end of it.

So maybe it’s not so bad being a bit of a white cloud… but still… I think we all like to have a little something that gets the juices flowing, the mind working, a bit of “yeah for me” moment… After all, that’s why we got into Emergency Medicine… at least for me… how about you?

Sometimes I have a hard time trying to separate fact from fiction; especially when patients start giving me a back story to explain why they haven’t had follow up for a medical problem, or how their narcotics got stolen/lost/misplaced, etc. I sometimes think, seriously? Is that really how bad your life is? Come on…

I know times are hard for a lot of people, but when you’re a 30-something, insulin-dependent, right AKA with non-healing wounds who social work bent over backward following your last admission to get you a clean place to live, home health care visits and arranged for a primary care physician so that you could regularly get medical care and, more importantly, your prescriptions, it’s poor form to miss appointments and get dropped from the practice.

Yes, I know it’s easy to get kicked out of your place within a month for having a dog which wasn’t allowed in the first place and which you acquired AFTER you moved in. What home isn’t complete without a loving pet? And, since you couldn’t afford a place before because of your limited SSI, I am sure adding vet bills, dog feed, and vaccinations to your budget will be no problem at all. And, sure, having a significant other who doesn’t work and who smokes despite the no-smoking policy of the building management is a problem especially when they’re not supposed to be on the property either. Yes, darn those apartment landlords and their stupid rules.

Now, I understand that you had previously been living in your car and had been lucky to have a nice place to live, but why couldn’t you drive that car to the appointment again? I’m sorry, you’re now having to live in it again… is it in working order? How did you get here again? What? It’s a legitimate question since you came 20 miles out of your way from your hometown to our E.D. Sure, yes, well, you’re in luck, we have no beds and are having to send all of our admissions north to our sister hospital. So, you’ll be closer to, um, home… and, besides, those social workers already know you and have done all of the leg work already, so there’s that too.

Then there’s the “I need a drug refill because my meds were stolen after I moved out from the last place I was in.” My answer is simply “drugs and scripts are like money, if you lose it, it’s gone and there’s no replacing it.” Besides, we have pain contracts with the local primary care M.D.’s, and they say, “No.” I still get some interesting stories, though, of backpacks being left “for just a second,” or of drugs disappearing “while I was taking a nap” or of pills in a lockbox in someone else’s house that mysteriously disappear when the person with the key leaves the house to go out to get some smokes. My favorite is the “I left them at my ex’s house, and now I can’t get them back.” “Did you file a police report?” “Well, um, yeah.” “Ok, let me talk to the police department and confirm the report number.” “Yeah, well, um.” “So, which police officer was it again..?” “Um, well, yeah it’s kinda like this…”

Mark Twain once said, “Truth is stranger than fiction, but it is because Fiction is obliged to stick to possibilities; Truth isn’t.” Twain must have worked in an E.D.

I can handle the abusive drunks. I can handle the tweekers who are “talkin’ to the devil.” I can handle the annoying drug seekers who are being seen for their weekly “dental pain” fix. But what I can’t seem to handle are the “walk in the door with my dead baby” parents.

I understand this was baby number 8 or 9. I know you can’t remember which since you don’t have custody of any of your other children, and sure, that makes it harder to keep track. And, yeah, she was only 2 months old; you hadn’t quite gotten used to having her around. She still hadn’t quite fit into the household routine.

Now, I know, she was a great baby because she slept through the night. And, yeah, who hasn’t put their baby to bed and then not checked on them for 15 hours. As long as they’re not crying, they’re fine, right? Yes, yes, I understand it was quite the family party and no one woke up before noon… or one… or two in the afternoon. I’m sure the baby was safe and sound on the bed with her full bottle from last night.

As for medical care, sure, being weighed once at the WIC office and being told that she’s “nice and healthy” is exactly the same as being seen by a pediatrician. It’s almost as good as getting vaccinated. I know that you’re busy and just couldn’t quite get in to have her seen at the pediatrician’s office, but I am sure all of your child’s health needs were met during that visit so you could get your much-earned government support.

Now, I have to let you know that I will be calling the local police, the coroner’s office, and Child Protective Services. They’re going to be asking a lot of questions. And, I know several of the maternity nurses are going to want some answers, too, when they find out that the “meth-addicted, breeds like a rabbit, that CPS was told about” at the time of your child’s birth is now bringing back that same child in not quite the same condition as when she left.

But seriously now, I don’t mind doing a peri-mortem exam in the E.D. with the coroner’s official. I’ve done physical exams on lots of two month olds. Granted, they are not usually wearing wet, soiled onesies. They usually aren’t stone cold with obvious lividity set in. They generally are not brought in wrapped in foul, cigarette and eau de dog scented blankets. But, I am a professional. I can maintain a clinical distance while performing my duties.

I am good at my job. And, I can make it through the end of my shift. And, through the next shift. That is… until I finally get home… until the night goes quiet… until I start to wonder what good I am doing at all… until I try to go to sleep with your daughter’s half open eyes and opened mouth still burnt in my brain as if asking me silently, “why?”

I know that the holidays can get really depressing for a lot of people, but I had three patients over the weekend that really got me depressed because of their situations. I always said that I would never make a good psychiatrist because I would tend to internalize and identify with my patients, and so that’s why I enjoyed surgery so much. There’s quite a bit of distancing that happens when you’re behind a mask looking at a square of skin.

As an E.D. doc, though, we’re up close and personal with a lot of our patients, so it’s back to internalizing and not having the luxury of a sterile sheet between you and your patient.

Patient One crashed their car. They are homeless, so their car is like their home. Everything they own is in there. They had just gotten kicked out of one “fleabag” motel and were on their way to find something better along the coast when they lost control on a curve. Now, all they have is the clothes on their backs. Well, actually in a hospital bag because they were stripped down to a hospital gown when they arrived. They’re bruised and battered and slightly torn. And, they have no one and no where to go. I can discharge them because, luckily, they didn’t suffer any major injuries. But, they have nothing. So they get admitted. Social Work and Discharge Planning can figure out what to do with them in the morning.

They used to have a life, and friends, and a home. But then they were forced to take early retirement from their work. They lost their home and their social network. They can’t afford housing on a fixed income. So they roam… in their car… from place to place.

Patient Two had a nice home, and a wife. Then their wife died and a part of them died too. So they turned to alcohol to help deal with the pain. Soon their nice home deteriorated as did their health. They have a neighbor who checks on them from time to time. Their neighbor brings them in whenever things get too bad. Patient Two can’t see their PCP because they have an outstanding bill, so the E.D. becomes their PCP. Diabetes out of control again? Yep. Bad cellulitis on your legs again? Yep. Anything new? Yep, pressure ulcers on my bottom from not getting up out of my chair for the last three days because my legs felt too bad. Am I going to be admitted? Yep.

Patient Three has a psych history. They’ve been in and out of the system their entire life which is only 50+ years long so far. They have the look of a 90 year old man. A neighbor stopped by because they hadn’t seen them for a few days and found them looking slightly worse than usual. Not eating or drinking. Somehow, though, they continue to smoke despite the rattling cough in their lungs. How the cigarette paper doesn’t just rip their Sahara Desert dry and cracked lips to shreds is beyond me. Must be the warm stale beer that somehow is within reach. Another admission for “Failure to Thrive.” It’s the least I can do.

A year ago I was in Vegas attending ACEP SA and looking forward to starting my new career as an attending physician. Now I am an attending physician looking forward to attending ACEP SA in San Francisco. It’s been quite the year, with a LOT of things learned along the way…

- With a good supporting staff you can run two codes at the same time.

- It’s never easy when a patient dies… it’s even harder when they come back to life after you’ve pronounced them.

- Suddenly the painful bread and butter patients become your bread and butter.

- I realized one day about six months in, that I will probably be here to see some of my pediatric patients grow up, some of my elderly frequent fliers die, and I will end up with some “private” patients.

- The surgeon who yelled at you one day will be the one who comes in and places a chest tube and central line for you the next when you’ve got a major trauma and a full board and growing rack.

- The Darwin Awards exist for a reason as exemplified by the girl with the C2 unstable fracture that left AMA because I wouldn’t “schedule” her a neurosurgery appointment and who “had too much to do” to be transferred to the other hospital up the road. She ended up driving herself about 2 hours later to the hospital and couldn’t be taken to surgery until later that night because she’d stopped at McDonald’s for a full meal… while wearing her C-collar at least…

- Really sick peds patients still scare me.

- Necessity really is the Mother of Invention

A year ago when I became an attending at this small rural hospital, I posted a blog about being thrown into the water not sure if I would sink or swim. A year later, I think I’ve mastered dog-paddling; this next year I will probably be learning some simple strokes. Just keep swimmin’ Just keep swimmin’… I look forward to seeing you in San Fran!!

Now that I’ve been working in this small community E.D. for a while, I’ve come to realize that you develop a very skewed view of people.

After seeing your fifth or sixth toothache of the day with severe dental caries, you begin to think that everyone smokes meth. After talking to your third or fourth 20-something who’s on disability for their “chronic pain,” you start to wonder who’s actually working in the community. When your second or third morbidly obese child comes from one of the outlying towns, you wonder about the strength of the local gene pool.

I’ve sometimes left the E.D. at night worrying about the people in my new community. While this community doesn’t have the Knife and Gun Club I left behind in the city where I trained, I feel like the perceived social environment may be more insidious. But, like I said, I have a skewed view.

Then one day I had an epiphany as I drove the main street of this small town. Even though it seems like we see half the town in one day in the E.D., it’s actually a very small percentage of the people who live here. The people who come through the E.D. aren’t the people I see working in the grocery store, delivering the mail, running the gas station, etc. Ok, well, sometimes those people do get hurt too, but they aren’t the chronic back pains, chronic dental pains, chronic anythings. They are the people with the emergencies. They are the people who I got into Emergency Medicine for… and somedays that thought is enough to keep me going through one more shift.